Upside down curve – Need Help!

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CatMomWendy

Member Since 2012
I adopted 13 year old Nelson in Sept. I was told he had been diabetic since he was 9. He was only on dry food when we got him. He was on Lantus 2 units twice per day. Within the first week, we took him to our vet and after blood work, upped the Lantus to 3 units twice per day. In Oct. I joined the discussion board and started learning about wet food (now feeding primarily FF Classics) so we started to wean him off the dry. He is still holding out just a little on demanding dry but we are down to 1/8 cup per day and we use it to “prime the pump” to get him to eat the wet at certain times of the day. Just this weekend I bought Stella and Chewy’s freeze dried raw food and he likes that so that will be a good transition and alternate food for him. I also feed pieces of cooked chicken (as a treat after BG testing) and have tried raw but he only eats that occasionally.

We learned about home testing and did our first curve in late Oct and tested every 3 hours (it was our first attempt at home testing). We are using a One Touch Ultra. Based on the results the vet upped the dose to 4 units twice per day starting 10/28/12. We started doing pre shot testing on 11/18/12 and found his before shot numbers were getting too low based on the 200 threshold (154, 66, 80 etc….I did not give insulin when that low). Talked to the vet who told me to take the dose to 3.5 units and I disagreed and said I felt that was too high based on the pre shot numbers we were seeing. He then suggested 3 which indicated to me he was guessing at this. Let me qualify that we love this vet because he helps us on the side with our other special needs cats by getting us supplies wholesale and even delivers them to our house. But I can also admit that I am more likely to get better advice here than from him.

I still wasn’t comfortable with giving 3 units and I honestly haven’t learned how to completely navigate all the information on the diabetes board and site. I may have hurt the situation by adjusting the dose up and down based on pre-shot numbers for a few days. I then read more and found out to be on a dose for 1-2 weeks and then adjust up or down based on readings so we (husband and I, not the vet) settled on going back to 2 units twice per day. We were finding some numbers still too low to dose but then his numbers 12 hours later would be high so then we would dose. We haven’t been home to do a curve until this weekend and here is where my concern lies:

Nelson’s curve was completely upside down yesterday! His numbers went higher and higher throughout the day and never hit a low point. We dosed last night and now this AM, he was at 78 and then 82 an hour later so again, I did not give a dose because I had to go to work and can’t be home to watch him.

I haven’t found/learned how to use a chart that I have heard about on the site so here are my times and actions from the past few days (we usually check at 6:40 AM and PM but sometimes stretch that an hour on weekends):

11-29-12
6:35 AM 65 no insulin given
6:35 PM 449 2 units given

11-30-12
6:40 AM 53 no insulin
6:30 PM 390 2 units given

12-1-12
7:35 AM 412 2 units given
7:30 PM 324 2 units given

12-2-12
6:35 AM 88 no insulin given
8:50 AM 233 2 units given
10:50 AM 355
12:45 PM 419
2:55 PM 459
4:55 PM 447
8:05 PM 424 2 units given

12-3-12
6:40 AM 78 no insulin given
7:48 AM 82 no insulin given

When we brought Nelson home, our vet prescribed the 10 ML vile of Lantus and we are still using that same vial (since Sept). Could the insulin be too old and losing effectiveness? I have since learned about the smaller vials in a 3 pack and will request that on our next refill. We also have learned about how to better handle the insulin (not from the vet but from this board) like not pushing any back into the vial, etc.

I need help figuring out what is going on with Nelson. Within my notes, I always record when Nelson last ate and whether it was hard or soft. One additional note: We have a total of 7 cats and when we are gone for a long weekend (like last weekend for Thanksgiving) we set out their hard food for them and the pet sitter gives them their soft when she does the PM visit. Nelson is given soft food on both the AM and PM visit but obviously can get into the dry which we know he did last weekend. I know that also throws off the numbers but short of isolating him in a room for the duration, we can’t handle it any other way at this point. I literally won’t be gone for a long weekend until Easter so I have many months to work on a solution.

Thanks in advance for any insight as to what is going on with Nelson and what I should be doing about it.
CatMomWendy
 
the first thing is to get rid of all the dry food in his diet. I understand how hard this can be when our first Diabetic was diagnosed it was very hard for us to get rid of the dry because we are also a multi cat family. We found the only way to handle weekends away was to take kitty with us or find someone to babysit all weekend not easy to do so kitty became a well travelled cat that loved to camp :) Other than that just keep what you are doing testing and getting more data to see how he reacts. I am sure some of the more experienced advice givers will be around soon to give you better advice
 
I am at work and can't post a lot...
my opinion from the numbers you have is that the dose is too high. ... the high numbers are most likely due to "bounces" caused by the lows. I think he has probably gone lower than what you caught on the meter...Will post more tonite.
Carl
 
You want to find a dose that you can comfortably give 2X a day. Giving it once a day doesn't work for a cat (as you can see from your numbers). It looks like Nelson may be a good candidate for possibly getting off of insuline eventually by those nice numbers, but you need to even him out and get rid of the bad food. If he insists on some dry food, are you at least using low carb (under 10%)? Lowering the dose will bring up the low end and lower the high end and then you can lower them both together. I'd drop back to 1U and start over there.
 
Here are the instructions on setting up the spreadsheet for tracking numbers: http://www.felinediabetes.com/FDMB/viewtopic.php?f=6&t=18207 Let us know if you need help with it.

I'm thinking once you find a constent dose he'll settle down. Consistency in dosing and feeding is very important with Lantus. You need to find a dose where you can safely shoot twice a day. I think it was wise of you not to bump up to 4u. Once Nelson is completely off the dry his numbers will drop just from that.

Keep up the good work - you're doing great!
 
I agree with Carl with respect to the bounces. What you're seeing isn't an inverted curve. Rather, it's the way Nelson's system is responding to the low numbers.

When a cat drops into a normal blood glucose (BG) range after having spent an undetermined period of time in a diabetic range, his body reacts as though those normal numbers were dangerously low. This can also happen if numbers drop fast (e.g., a cat that drops from a pre-shot range i9n the 500s to the 200s by nadir). We refer to this protective response as a bounce. What happens is that the pancreas releases a stored form of glucose (i.e., glucagon) along with counterregulatory hormones that spike numbers up into higher ranges. While these bounces are annoying to us and probably don't make our kitties feel all that great, they are not dangerous. As you cat spends longer periods of time in normal numbers, the bouncing should slow down or stop.

Nelson was in the 300s on 12/1 at your PMPS. By your AMPS, he was at 88. You skipped the shot and roughly 2.5 hours later his numbers were on the rise. Even though you shot late, his numbers continued to rise. That's the bounce. By this morning, it looks like he'd cleared the bounce.

There are a couple of observations I'd make. Try to find a shot time that you can stick to. Lantus likes consistency both in terms of giving a shot every 12 hours and in terms of dose. Doses need at least 3 days (6 cycles) to settle. Dose adjustments are based on the nadir. While it's important to have a pre-shot value to know if it's safe to shoot, doses are changed based on the lowest point in the cycle. As others noted, you may need to reduce Nelson's dose if you're finding that his numbers are lower than where you're comfortable shooting.
 
While you are still using any dry food, make the amount consistent am & pm so it has a similar amount of effect on the glucose levels through the cycle. If possible, you might use a timed pet feeder to portion it out. Lots of folks like the Pet Mate 5.

It also works great with the canned food to do this if you have a cat that scarfs his meals. You want the food mostly delivered in the first half to two thirds of the 12 hours, so food isn't increasing the glucose levels when the insulin is wearing off for the cycle.
 
Thank you all for your input! I am really worried I am going to hurt Nelson by these drastic swings. I want to stabilize him so he doesn't experience such dramatic changes. Good to know the changes we have made to his diet are starting to make a difference.

So what I am hearing is that Nelson's dose is too high and causing a bounce. I need to find a dose where his AM and PM numbers are safe to dose. I am still unsure about how to calculate that based off a nadir. Just to clarify for me - that should be the lowest number we see when doing a curve? I won't be able to do a curve until next Sunday. Can I safely lower his dosage now without knowing what the nadir is? If he is currently at 2 units twice per day, what is the predicted dose to aim for without waiting another week? One person suggested reducing to 1 unit twice per day. My gut tells me to change more gradually (1.75 or 1.5) but I am by no means confident on that.

Regarding the feeder, I have seen other people mention those on the Facebook page. The one problem I see with that is my one cat Dexter (who is a registered therapy cat) is too smart for his own good. I know he will learn what that noise is and will stand guarding waiting or come running when he hears it and Nelson won't get the food. Short of committing Nelson to his own room which I don't want to do, I think the others will all eventually learn what the feeder does too. How have others won that battle?
 
Can you get a third test in each day about halfway through either the AM or PM cycle? I know this can be hard to schedule, but it can be done. Bandit's shots were at 7am/7pm, so I used to grab one before bed (10-11pm) and then set an alarm to get one at 1 am (6 hours after the shot) and go right back to sleep. Without those daily nadirs, regulation is much more difficult, as the nadirs tell you how much the insulin is working in each cycle. If you're only getting them once a week, you don't know if he could have had a bounce that day (like Sienne described, a high number resulting from a lower number the day before), or if the dose needs to raised. So you're mostly guessing where the dose should be, rather than knowing where it should be. It's kind of like shooting at a bullseye whie peering through the cracks of your fingers, rather than shooting with your full vision. The more you hit the target, the better control you'll have over his BG, so you want a full picture of what's going on, rather than just 1/7th of the puzzle.

Those nadir tests seem like a pain to get at first, but they will make your dosing decisions much, much safer and easier.

With my two cats, Bandit was a gobbler, and Gabby was much less food aggressive, so I had to do a little training. I bought two feeders, and I fed the cats every meal, feeder or no, at opposite ends of the kitchen. I also only fed them enough that I knew Gabby (the picky one) would eat all in one sitting. So when I set the feeders, I left each one at opposite ends of the kitchen, and while Bandit might scarf his food just a little faster and run to clean up Gabby's, she was always nearly done so it wasn't a huge deal.
 
We have done a few 12:30 AM tests (set the alarm) so we can do that this week to see. He is due for his shot in just a few minutes. Not sure what to do for a dose....I think we will back down to 1.5 units and see what that does over the next few days. Seeing the bounces just really scares me. I am sorry if I used the 911 inappropriately on my first message today but the high numbers made me think I was hurting more than helping Nelson who we have come to love dearly.
 
Getting those extra tests will really help on deciding the dose. Its hard to tell where to go without really knowing what's happening before that low number.

Its seems really scary to see those high numbers and think about lowering the dose. If it is in fact a bounce, think about it like a superball. If you drop a superball lightly it bounces lightly and evenly. The harder you throw the superball at the floor, the harder and higher the bounce is going to be.

Without seeing what is happening before those low numbers, its just everyone's best guess that the high numbers are a bounce. The important thing is to find a dose that will keep Nelson safe that you are comfortable giving 2X a day. If you think 1.5U is where you may be comfortable doing that, then start there and get those tests.

Those lows are coming at the AMPS, so try to set an alarm to catch some middle of the night mid-cycle tests so you can find out what he is doing in there and be better equipped to make those dosing decisions. Its hard to give up that sleep, but trust me, you will feel lest panic and worry and more in control when you start seeing the pattern and understanding what the insulin is doing and being able to make decisions feeling better equipped and informed.
 
Better to be a bit high than too low. The latter can kill quickly with little time to intervene.

It'll be OK to drop to 1 unit because Lantus is a depot insulin and has some carryover shot to shot, so it will reduce over 3-5 days before it settles into a stable pattern.
 
We adjusted Nelson's dose to 1.5 units last night. His pre-shot last night was 248 (and that was after not having insulin in the AM). We got up at 12:30 and he was 284 so not sure if that was nadir since it was higher. This AM at pre-shot he was 319 so we dosed again at 1.5 units. We will repeat the midnight tests each night this week.
 
Don't worry about those 200-300s today. His blood sugar is only higher now because it dropped lower yesterday. Rebound hyperglycemia can take up to 72 hours to clear from his system, but usually it takes less time than that. So you'll see things go back down again in the next day or two. Lantus takes several days of holding the same dose to see what is going on, so one of the hardest lessons to learn with this insulin is patience. Regulation is a marathon, not a sprint, so you can't get freaked out by individual high readings what you're looking for is trends and patterns over several days and weeks.

Once you are able to hit that right dose, his numbers will stop bouncing up and down and level out. But the only way to do that is through trial and error, with nuanced dose adjustments. I'm really glad you're able to get those nadir checks--I would have strongly recommended dropping down to 1u if you couldn't. As it is, 1.5u still may be too much insulin (most cats on a low carb canned or raw diet don't need much more than 1u of insulin), so if you're shooting that much you'll need to keep a careful eye. In most cases, you want to try and approach the right dose from underneath, because as you're finding out, too much insulin will keep BG just as high as too little insulin.

One other thing I would highly recommend doing is setting up a spreadsheet. Here's instructions on how to do so: http://www.felinediabetes.com/FDMB/viewtopic.php?f=6&t=18207. The spreadsheet is not only an incredibly useful tool that allows you to visualize your data, but it's also really helpful if you need to get dosing advice from the experienced Lantus users here on the boards. :smile:
 
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